Chapter 12

The Question of Urinary Tract Infections and Infant Circumcision

In 1989 the American Academy of Pediatrics, which had repeatedly pronounced infant
circumcision unnecessary since the early 70’s, 1 reviewed the subject again in light of more recent data on urinary tract infections. They released a fairly neutral statement, differing only slightly from their previous pronouncements. 2 Upon release, their verdict immediately underwent immense media distortion which has led the public to believe that the AAP is more pro-circumcision than they truly are. In 1999 the AAP restated: “…these data (in support of the operation) are not sufficient to recommend routine neonatal circumcision. … the procedure is not essential to the child’s current well-being…” 3

In 1985 Maj. Thomas E. Wiswell, a U.S. Army physician at Brooke Army Medical Center in San Antonio, TX., reported his observations of a significantly increased incidence of urinary tract infections among intact (non-circumcised) male infants over that among circumcised male infants. Upon reviewing the medical records of all infants born at Brooke Army Medical Center between Jan. 1, 1982 and June 30, 1983, out of 1,919 circumcised male infants, 4 subsequently experienced infection of the urinary tract (0.21%). Out of 583 intact male infants, 24 experienced urinary tract infections during infancy (4.12%) In other words roughly 1 out of 500 circumcised male infants experienced uti’s, while approximately 1 out of 25 intact male infants experienced uti’s, a 20-fold increase in the rate of urinary tract infection among intact infant boys in this group. 4

Prior to these observations Wiswell had opposed routine infant circumcision, but upon the publication of this and several subsequent similar articles, he has become an avid proponent of the controversial surgery.

Infection of the urinary tract is virtually always caused by contamination from fecal bacteria. A suspected contaminant is stool in the baby’s diaper.

Wiswell comments: “The male urethra is apparently more exposed to contaminating fecal bacteria than is the female urethra. The measured concentration of periurethral aerobic flora decreases with increasing age. Circumcision may reduce the extent of meatal contamination and thereby, decrease the likelihood of bacterial ascent into the bladder. With increasing age, the foreskin is more easily retracted. Penile hygiene should subsequently improve, resulting in decreased bacterial exposure and fewer urinary tract infections.” 5

Most of the infants in Wiswell’s above mentioned report were less than 3 months of age. Out of a total of 5,261 infants, 41 in all experienced urinary tract infection. (13 girls out of 2,759 also were included in the report.) 6

It would seem that the foreskin would protect the glans from simple fecal contact, as it is known that the foreskin serves as a covering for the more delicate glans. Therefore Wiswell’s findings are surprising, if not arousing of suspicion. Some commentators have hypothesized that the enclosed area under the foreskin could provide a breeding ground for bacteria, while the exposed glans of the circumcised infant penis would be less likely to harbor such contaminants. However, the entirely sealed structure of a normal newborn’s glans and foreskin comprises virtually no space, resembling more closely the nature of an interior organ. The only substance with which it should ever come in contact would be the baby’s own urine which normally is sterile and harmless. When left alone the normally tightly sealed newborn foreskin gradually separates from the glans of the penis – a process which can take from several months to several years. Therefore it is curious that circumcision would apparently reduce the possibility of meatal contamination when the absence of the foreskin creates an exposed meatus. The rates of urinary tract infections among infants and young children decrease with age. However, toilet training with subsequent absence of soiled diaper contact is probably a more significant factor than age or foreskin retractility.

In a subsequent report Wiswell observed no urinary tract infections among 1,575 circumcised infants (0%), while 8 urinary tract infections occurred among 444 intact male infants (1.80%). 7

In yet another, much larger study, upon reviewing 10 years worth of medical records of all infants born at Brooke Army Medical Center, Wiswell reported the following figures: Out of 175,317 circumcised male infants, 193 (0.11%) developed urinary tract infection. Out of 46,112 intact male infants, 468 (1.12%) experienced urinary tract infections. The rate of uti’s among the intact males in this study was roughly 1/4 that of his first study, and the intact to circumcised ratio of uti occurrence is roughly half as large. In his 1987 study, roughly ten times as many infants in the intact group experienced uti’s than did the circumcised group. Urinary tract infection occurred among approximately one out of one hundred intact baby boys, and approximately one out of a thousand circumcised baby boys. 8

Wiswell notes that the rate of infant male circumcision had significantly decreased over the previous decade. (From 1975-1979, 84.3% of baby boys were circumcised, while from 1980-1984, 74.0% were circumcised, a greater than 10% decrease.) He predicts that increasing incidences of infant uti will occur as a result of our nation’s declining rate of infant circumcision. 9

At face value one could conclude that a valid health benefit of infant circumcision has been observed. The intact baby movement has focused upon infant pain and trauma imposed by circumcision, the invalidity of purported health claims, the protective role of the foreskin, the value of the wholeness of the body in its unaltered state, and the personal rights of the infant. But when this information was originally compiled, we knew nothing of infant urinary tract infections. In light of these findings, have we made a mistake?

OBSERVATIONS REPORTED BY OTHERS

Many doctors have questioned Wiswell’s findings, including several whose letters subsequently appeared in PEDIATRICS:

Cunningham comments: “There being no plausible explanation for such a finding, before we accept any cause and effect relationship and the possible consequence (reversal of the worldwide trend away from routine circumcision of the newborn), we should seek alternative explanations. 10

Cunningham mentions socio-cultural differences between families of circumcised and intact infants, interventive care of the infant foreskin and the catheterization process (sometimes used for collecting urine samples) as possible variables. 10

Cunningham also mentions a recent Swedish study which reported an incidence of only 0.56% (1/200) of uti’s among infant males. (Presumably all were intact since circumcision is rare in Sweden.) 11

Altschul analyzed data on all infants younger than 1 year of age with urinary tract infection admitted to Northwest Region Kaiser Foundation Hospitals from 1979 to 1985. 25,000 infants were born in those hospitals over that 6 year period, during which the rate of newborn circumcision declined from 83% to 76%. 19 infants had the diagnosis of urinary tract infection. Five were boys and fourteen were girls. Presumably half of the 25,000 total infants were boys. Hence there were five cases of uti among approximately 12,500 baby boys. The 13% to 24% of baby boys left intact over those years translates as approximately 2500 intact infant males. Of the five infant boys with uti, one was circumcised, two had congenital defects (kidney obstruction), and two were normal intact males. Altschul cites a 3/2500 rate of infant uti in this report (he includes one of the infants with congenital defects among the intact boys) for a rate of 0.12%, or roughly 1 out of 833 cases of uti among intact infant males. 12 This is considerably lower than Wiswell’s figures which ranged from 1.1% (1/100) to 4.1% (1/25.)

But there exists no universally agreed upon standard or percentage by which endorsement or rejection of a medical practice should be based.

Non-Surgical Preventability

“Leave it alone” has been a virtual battle-cry in instructing people in proper care of the child’s foreskin. An infant’s foreskin is normally tight and unretractile. Virtually all problems known to be associated with the foreskin, such as infection, or phimosis (abnormal tightness) are caused by adults’ attempts to force it loose for “cleaning.”

Peaceful Beginnings, NOCIRC and most similar organizations support a “total hands off” philosophy towards care of an infant’s or young child’s foreskin. Although most foreskins become loose and retractile by age 3 or 4, in most little boys there is rarely anything there to clean. Not until adolescence, when penile size increases and adult body odors begin does regular simple retraction of the foreskin during bathing become advisable. 13 14 15

The area between the foreskin and glans in a normal newborn is a sealed, sterile site. Infecting bacteria do not originate under the foreskin. Urinary tract infections are normally caused by pathogens which originate in the bowel from fecal material. Therefore it can only reach the foreskin and the urethra and bladder if the infecting agent somehow becomes introduced into this area. Many have suggested that mis-advised, interventive care of the infant foreskin could be a means of introducing contaminants into the urinary tract.

In Wiswell’s report:

“The parents of all male infants were advised to routinely clean the glans with a mild soap and water solution. The parents of uncircumcised male infants were additionally counseled to gently retract the foreskin to allow the easily exposed portion of the glans to be cleaned…” 16

In response other doctors have countered:

“… the advice given to the parents, i.e., to retract the foreskin, led to trauma and thereby opened a portal of entry for pathogenic bacteria …” 10

“As it is generally accepted that the prepuce is adherent to the glans penis and that retracting the foreskin in an infant may traumatize the penis and prepuce, I would wonder whether this advice may have contributed to the increased urinary tract infection rate seen in the uncircumcised male infants. 17

“After 40 years of pediatric practice, I am firmly convinced that the best hygiene is to keep hands off and leave the prepuce alone. I have had many infants with problems from inadequate and poorly done circumcisions; similarly, I have had many uncircumcised infants who got into trouble when a “helpful” nurse, doctor, or grandmother forcibly retracted and cleaned a tight prepuce. … I have never seen a problem in an uncircumcised infant when the mother just left it the way the Lord made it — no retractions, no vigorous cleansing, just left it alone. … Historically, many “scientific interventions” have proven to be more injurious than helpful. Perhaps vigorous cleaning of the prepuce and glans are in that category.” 18

An even more intriguing consideration concerning infant colonization of maternal intestinal flora is reported in a recent Swedish study:

Home birth proponents emphasize that at home one is surrounded by one’s “own” germs, to which most individuals have natural tolerance. Therefore, despite normally less than antiseptic conditions, a mother and her baby are usually less likely to become infected following delivery at home than in a hospital or birth center. Large numbers of people congregate in hospitals, while particularly virulent strains of bacteria abound that have become genetically resistant to antibiotics and antiseptic cleaning solutions. Hospital employees and patients, commonly develop staphylococcus infections. The fresh wound of an infant’s circumcision has been observed to be a portal of entry for infection, sometimes with tragic outcome. 19

The authors of the Swedish study under discussion consider the importance that newborn babies become colonized at birth with familiar bacteria from their own mothers’ intestinal tracts rather than from foreign infectious agents in the hospital environment.

In their words:

“Retrospective studies suggest that circumcision of newborn boys will reduce the frequency of male early infantile urinary tract infection (UTI) by about 90%. If they are correct, this will be the first known instance of a common potential lethal disease being preventable by extirpation of a piece of normal tissue. To reconcile the phenomenon with existing views of evolution and biology, it is suggested that the effects of one unphysiological intervention are counterbalancing those of another — i.e., colonisation of the baby’s gastrointestinal tract and genitals in maternity units by Escherichia coli strains of non-maternal origin, to which the baby has no passive immunity. As an alternative to circumcision to prevent early infantile male UTI, more natural colonisation could be promoted by strict rooming-in of mother and baby or by active colonisation of the baby with his mother’s anaerobic gut flora. …

“…in biologically natural settings, when giving birth in the squatting or kneeling position, mothers often defaecate during delivery and thus colonise the baby with their own aerobic and anaerobic intestinal flora. Together with this gift they provide specific protection — immunoglobulins transferred before delivery through the placenta and later through breast milk. …

“If the composition of the normal flora is as important as many think it is, the colonisation of newborn babies may be too serious a matter to be left to chance in environments — the modern obstetric hospital or the neonatal intensive care unit – which from a biological point of view are unphysiological and possibly hazardous. …

Attempts to manipulate the faecal flora might in the long run be a more physiological approach than to remove the prepuce from all newborn boys. Pending further research strict rooming-in might increase the likelihood of the baby being colonised by maternal strains.” 20

Further information on the rooming in status of the Wiswell and Altschul studies, including the extent to which each infant was kept in the central nursery (even if he “roomed in” for a portion of the hospital stay), might shed further light on Winberg’s hypothesis. (Kaiser hospitals, from which the Altschul data was obtained, are known to offer rooming in.)

Proponents of breastfeeding can cite a long list of scientifically documented health advantages of breast milk over infant formula. Breast milk has now been found to contain high contents of oligosaccharides (a type of carbohydrate), which in turn are excreted in the urine of both nursing mothers and their breastfed babies. In one study oligosaccharides have been tentatively demonstrated to cause inhibition of bacterial adhesions which in turn may have a preventative effect against urinary tract infections. 21

The breastfed/bottlefed status of the infants in the Wiswell and Altschul reports would be of interest to note. Bottlefeeding appears to be another “unphysiological intervention” which can increase the likelihood of infant uti.

The Winberg, et al and Coppa, et al studies suggest that the mother who keeps her baby with her from birth on and who breastfeeds can safely leave her infant son intact with scarce risk of urinary tract infection.

Comparative Pain and Trauma

Severe pain and trauma is inflicted upon a helpless newborn when undergoing circumcision. Our literature abounds with graphic descriptions of infants strapped to “circi” boards, screaming frantically while their genitals are clamped and cut. Usually no anesthesia is used. (Use of a local injection has been purported to reduce the infant’s crying time by half – which still equals much trauma. 22 )

Urinary tract infection is also a highly stressful, traumatic event characterized by fever and painful urination. Other symptoms can include lethargy, irritability, and lack of appetite. Wiswell describes vomiting and diarrhea occurring in a few patients, although none with jaundice or “failure to thrive” syndrome. 23

He describes urine samples obtained by catheterization, and less frequently by suprapubic aspiration (bladder tap.) Blood samples were taken in all infants and lumbar puncture (spinal tap) was obtained in some. 23

How the stressful, traumatic experience of uti would compare to the obvious stress and trauma of circumcision of a healthy infant would be difficult to evaluate. The circumcised baby experiences pain and trauma and permanent body alteration/mutilation with the loss of the protective foreskin. Usually he heals normally, although many complications – infection of the circumcision wound, hemorrhage, removal of excessive skin, injury to the glans and/or surrounding tissues, meatal ulceration (urine burns on the exposed glans), and in rare cases loss of the penis and death — have all been well documented.

The baby with a urinary tract infection undergoes pain and trauma. Unlike the circumcised baby, he does not undergo permanent body alteration with loss of a normal, useful body structure. Urinary tract infection is normally readily treatable with antibiotics. Although rare cases of long term detrimental effects of urinary tract infections have been mentioned in the literature, no honest evaluation has been made to consider this alongside the known, well-documented long term complications of circumcision.

Wiswell clearly states:

“It is unclear at this time whether the increase in incidence of urinary tract infection in uncircumcised infants has any long-term medical significance other than the immediate cost of diagnosis, treatment, and follow-up evaluation of the acute infection.” 24

Elsewhere the same author states:

“In the preantibiotic era, the mortality from urinary tract infection was 20%, whereas an additional 20% may have ended up with hypertension and chronic renal failure.” 25

However, today with readily available antibiotics, the above consideration cannot apply.

If the concern is towards preventing a high stress/trauma event for an infant, or balancing medical costs between that of universal circumcision versus individual costs of medical treatment for urinary tract infections, a proposal of routine circumcision for all infants to purportedly prevent a small number of urinary tract infections hardly appears to be valid medical logistics.

Medical “Just In Case-ism”

The proposal to destroy hundreds, if not thousands, of infant foreskins to possibly prevent one instance of urinary tract infection, is yet another example of medical “just in case-ism” with which the public has been bombarded. Soaring Cesarean rates, universal use of fetal heart monitors, hysterectomies, mastectomies, dilation and curettages, and routine episiotomies are but a few questionable, invasive procedures which frequently have failed to improve or preserve overall patient health.

As consumers we have a responsibility to ourselves and to our children to be aware and informed about all medical procedures. The orientation of the medical profession reflects an aggressive, “cut it away” approach to health care. But most surgery, particularly non-emergency surgery, has feasible noninterventive alternatives.

The Purpose of Surgery

Most surgery involves correcting an abnormal body condition — i.e. repair of injury, removal of diseased tissue, or correction of a deformity. Some surgery is cosmetic — which can only be considered ethical if chosen by the individual.

Birth associated surgeries such as episiotomies and Cesareans have been sources of intense debate within obstetrical circles.

But can surgery be preventative medicine? Never has the routine destruction of a normal body part been proven to be an effective health measure.

Other body structures, such as ears, toes, or fingernails could be similarly viewed as superfluous with medical data constructed around an amputative philosophy. For example, a widespread practice of routine toe amputation at birth could be demonstrated to spare the individual of a lifetime of bouts of corns, bunions, and athlete’s foot, and save him from the nuisance of washing between the toes. We dismiss any similar amputative philosophy as ludicrous, hence proving that a mystical irrationality surrounds circumcision and foreskins that we apply to no other normally occurring body part.

“Knives Versus Washcloths” — Medical Dictatorship Versus Wholeness of the Body and Personal Autonomy

Many people have pointed out that any and all purported “health benefits” related to circumcision are merely a side issue to avoid facing the facts clearly.

John Erickson, an outspoken advocate of infants’ rights has stated:

“When you cut off a baby’s foreskin, you are literally censoring his life. The vast majority of males who are not circumcised value their wholeness — even beyond price — and keep their foreskins intact, for the same reason they keep the rest of their bodies intact. When you circumcise a baby, you are cutting off a part of his penis that you can cut off only because the person you’re cutting it off of can’t protect himself because he is a baby. … Many males circumcised as babies see themselves as harmed by that amputation — regardless of the reason they were circumcised (emphasis mine) — just as they would see themselves as harmed if any other healthy, sensitive, normally functioning part of their body had been cut off. The endlessly debated “health benefits” of infant circumcision are therefore a false issue and would not justify depriving a baby of his foreskin even if they were real.” 26

Warren F. Smith, another activist in the intact baby movement, has quipped:

“Never ask the barber if you need a haircut.” (28.)

Conclusion:

When my fourth son was born in 1985 I found the matter so absurdly simple as to warrant hardly any thought or action at all. During his infancy I was thankful to forgo subjecting him to the traumatic, violating experience that his brothers experienced. I was also thankful that he could be spared the troublesome problems with meatal ulceration that my older sons experienced as infants.

I later gave birth to another baby, a daughter in 1989. Had this baby been another boy, he too would have remained intact.

Peaceful Beginnings continues to oppose routine infant circumcision as highly traumatic to newborn infants, of dubious benefits, and violating of individual, personal rights with which an infant or small child is not afforded if his foreskin is taken away. We welcome the challenge of investigating new findings which may support or refute this stand.

References:

  1. Thompson, Hugh C., M.D.; King, Lowell R., M.D.; Knox, Eric, M.D.; & Korones, Sheldon B., M.D. “Ad Hoc Task Force on Circumcision – Report” PEDIATRICS, Vol. 56, No. 4, October 1975.
  2. Schoen, Edgar J., M.D.; Anderson, Glen, M.D.; Bohon, Constance, M.D.; Hinman, Frank Jr., M.D.; Poland, Ronald L., M.D.; & Wakeman, E. Maurice, M.D. “Report of the Task Force on Circumcision”
    American Academy of Pediatrics – Reprint, 1989. (The above report pronounced the Wiswell studies inconclusive, stating: “It should be noted that these studies in army hospitals are retrospective in design and may have methodologic flaws. For example, they do not include all boys born in any single cohort or those treated as outpatients, so the study may have been influenced by selection bias.)
  3. Lannon, Carole M., M.D., MPH; Bailey, Ann Geryl Doll, M.D.; Fleishman, Alan R., M.D.;
    Kaplan, George W., M.D.; Swanson, Jack T., M.D.; & Doustan, Donald, M.D. “American Academy of Pediatrics Task Force on Circumcision. Circumcision Policy Statement” PEDIATRICS 1999; 103(3): 686-693.
  4. Wiswell, Maj. Thomas E., MC Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants PEDIATRICS, Vol. 75, No. 5, May 1985, p. 901-903.
  5. Ibid. (Wiswell’s resources: Stamey, T.A.: Urinary Infections in Infancy and Childhood, in Pathogenesis and Treatment of Urinary Tract Infections. Baltimore , Williams & Wilkins, 1980, p. 294-296.; Lincoln K., Winberg J.: Studies of Urinary Tract Infections in Infancy & Childhood. Acta Paediatr Scand, 1964; Vol. 53, p. 307 – 316.; Bollgren I., Winberg J.: The Periurethral Aerobic Bacterial Flora in Healthy Boys and Girls. Acta Paediatr Scand 1976; Vol. 65, p. 74-80.)
  6. Ibid., p. 902.
  7. Wiswell, Maj. Thomas E., MC Corroborative Evidence for the Decreased Incidence of Urinary Tract Infections in Circumcised Male Infants PEDIATRICS, Vol. 78, No. 1, July 1986, p. 96-99.
  8. Wiswell, Maj. Thomas E., MC Declining Frequency of Circumcision: Implications for Changes in the Absolute Incidence and Male to Female Sex Ratio of Urinary Tract Infections in Early Infancy
    PEDIATRICS, Vol. 79, No. 3, March 1987, p. 338-342.
  9. Ibid., p. 341.
  10. Cunningham, Nicholas, M.D., Dr. PH Division of General Pediatrics, Department of Pediatrics,
    Clinical Pediatrics and Public Health, College of Physicians and Surgeons of Columbia University, New York, NY. “Circumcision and Urinary Tract Infections” PEDIATRICS, Vol. 77, No. 2, February 1986, “Letter to the Editor”, p. 267.
  11. Tullus, K. & Kallenius, G. “Epidemiological Aspects of P-fimbriated Escherichia Coli IV. Extraintestinal E. Coli Infections Before the Age of OneYear and Their Relation to Fecal Colonization with P-fimbriated E. Coli” Acta Paedr Scand Vol. 76, 1987, p. 463-469.
  12. Altschul, Martin S., MD “Larger Numbers Needed” PEDIATRICS, Vol. 80, No. 5, November 1987, p. 763.
  13. Oster, Jakob “Further Fate of the Foreskin — Incidence of Preputial Adhesions, Phimosis, and Smegma among Danish Schoolboys” Archives of Disease in Childhood, Vol. 43, April 1968, p. 200-203.
  14. Gairdner, Douglas, D.M. “The Fate of the Foreskin – A Study of Circumcision” British Medical Journal, Dec. 24, 1949, p. 1433-1437.
  15. Reichelderfer, Thomas E., M.D. & Fraga, Juan R., M.D. Care of the Well Baby (reprint)
    by Shepard, Kenneth S., M.D. (ed) J.B. Lippincott Co., 1968, p. 10.
  16. Wiswell, PEDIATRICS, July 1986, p. 96.
  17. Malleson, Peter, M.B., B.S., MRCP Pediatric Rheumatology, B.C. Children’s Hospital Vancouver, British Columbia, Canada “Prepuce Care” PEDIATRICS, Vol. 77, No. 2, February 1986, “Letter to the Editor”, p. 265.
  18. Watson, Stan J., M.D. “Care of Uncircumcised Penis” Palm Springs, CA. PEDIATRICS, Vol. 80, No. 5, November 1987, p. 765.
  19. Kravitz, Harvey, M.D.; Murphy, John B., M.D.; Edadi, Kasem, M.D.; Rosetti, August, M.D.; & Ashraf, Hebatollah, M.D. “Effects of Hexachlorophene-Detergent Baths in a Newborn Nursery with Emphasis on the Care of Circumcisions” The Illinois Medical Journal, Vol. 122, No. 2, August 1962, p. 133-139.
  20. Winberg, Jan; Bollgren, Ingela; Gothefors, Leif; Herthelius, Maria; & Tuelus, Kjell “The Prepuce: A Mistake of Nature?” The Lancet, March 18, 1989, p. 598-599.
  21. Coppa, Giovanni V.; Gabrielli, Orazio; Giorgi, Pierluigi; Catassi, Carlo; Montanari, Maria P.; Varaldo, Pietro E.; & Nichols, Buford L. “Preliminary Study of Breastfeeding and Bacterial Adhesion to Uroepithelial Cells” The Lancet, Vol. 335, #8689, March 10, 1990, p. 569-571.
  22. Stang, H.J.; Cunnar, M.R., & Snellman, L., et al “Local Anesthesia for Neonatal Circumcision. Effect on Distress and Cortisol Response” JAMA, 1988, Vol. 259, p. 1507-1511.
  23. Wiswell, PEDIATRICS, 1985, p. 902.
  24. Ibid., p. 903.
  25. Wiswell, Thomas E., M.D. (Letter to ed., reply to Altschul’s “Larger Numbers Needed”) PEDIATRICS, November 1987, p. 764
  26. Erickson, John (Letter to Editor) The Baby News Connection Journal, San Antonio, TX., May/June 1990, Vol. 6, No. 2.
  27. Romberg, Rosemary Circumcision: The Painful Dilemma c. 1985, Bergin & Garvey, S. Hadley, MA., p. 247-248.
  28. Smith, Warren F. (personal correspondence.)
  29. Rovner, Sandy “Doctors at Impasse Over Circumcision of Male Newborns” Anchorage Daily News, May 17, 1990, p. H1 & H2.

INFORMATIONAL RESOURCES

http://adc.bmj.com/content/90/8/853.full
http://adc.bmj.com/content/early/2008/10/06/adc.2008.144063.abstract
http://adriennecarmack.com/preventive-male-infant-circumcision/
http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/modernmedicine/modern-medicine-feature-articles/circumcision-reduces-li?page=full (Morris, Wiswell – pro circ advocates.)
http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/modernmedicine/modern-medicine-feature-articles/circumcision-reduces-li?page=full (Wiswell – pushing circumcision for uti prevention)
http://healthland.time.com/2012/07/09/study-uncircumcised-boys-have-a-higher-risk-of-uti/ (pro circ but good responses from intactivists)
http://link.springer.com/article/10.1007/s10461-014-0846-4?no-access=true
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009129.pub2/abstract
http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.1999.00104.x/abstract (no connection to circ status in adult males)
http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2003.04113.x/full
http://pediatrics.aappublications.org/content/early/2013/03/12/peds.2012-2896.full.pdf
http://womanuncensored.blogspot.com/2010/01/circumcision-is-for-weiners.html (cartoon at end of article)
http://www.bmj.com/content/317/7171/1473.1.full
http://www.cirp.org/library/disease/UTI/
http://www.cirp.org/library/disease/UTI/altschul1990/
http://www.cirp.org/library/disease/UTI/amato/
http://www.cirp.org/library/disease/UTI/anderson1/
http://www.cirp.org/library/disease/UTI/chessare/
http://www.cirp.org/library/disease/UTI/cohen/ (uti’s post circumcision)
http://www.cirp.org/library/disease/UTI/coppa/
http://www.cirp.org/library/disease/UTI/craig/
http://www.cirp.org/library/disease/UTI/cunningham/
http://www.cirp.org/library/disease/UTI/ginsburg/
http://www.cirp.org/library/disease/UTI/goldman/
http://www.cirp.org/library/disease/UTI/gothefors1/
http://www.cirp.org/library/disease/UTI/hanson1/ (breastfeeding * fewer uti’s)
http://www.cirp.org/library/disease/UTI/herzog2/
http://www.cirp.org/library/disease/UTI/kwak1/
http://www.cirp.org/library/disease/UTI/littlewood1/
http://www.cirp.org/library/disease/UTI/llorens/
http://www.cirp.org/library/disease/UTI/marild/””
http://www.cirp.org/library/disease/UTI/marild3/
http://www.cirp.org/library/disease/UTI/marild4/
http://www.cirp.org/library/disease/UTI/maskell/UrinPathMale.pdf
http://www.cirp.org/library/disease/UTI/mccracken/
http://www.cirp.org/library/disease/UTI/mueller/
http://www.cirp.org/library/disease/UTI/newman1/
http://www.cirp.org/library/disease/UTI/outerbridge/ (breastfeeding & fewer uti’s)
http://www.cirp.org/library/disease/UTI/outerbridge/ (immunological functions of prepuce)
http://www.cirp.org/library/disease/UTI/pisacane/ (breastfeeding & uti’s)
http://www.cirp.org/library/disease/UTI/pisacane1992/
http://www.cirp.org/library/disease/UTI/robson1/
http://www.cirp.org/library/disease/UTI/singh-grewal1/
http://www.cirp.org/library/disease/UTI/smith1916/
http://www.cirp.org/library/disease/UTI/sreenarasimhaiah1/
http://www.cirp.org/library/disease/UTI/thompson/
http://www.cirp.org/library/disease/UTI/to/
http://www.cirp.org/library/disease/UTI/to2/
http://www.cirp.org/library/disease/UTI/vanhowe/
http://www.cirp.org/library/disease/UTI/vanhowe_uti2005/
http://www.cirp.org/library/disease/UTI/winberg-bollgren/
http://www.cirp.org/library/disease/UTI/winberg-bollgren2/
http://www.cirp.org/library/general/wallerstein/
http://www.cirp.org/library/hygiene/watson1/
http://www.cirp.org/library/statements/aap1999/
http://www.cirp.org/library/statements/cps3/
http://www.drmomma.org/2009/09/uti-testing-on-boys-do-not-retract.html
http://www.drmomma.org/2009/12/how-foreskin-protects-against-uti.html
http://www.healthline.com/health/urinary-tract-infection-children#Overview1
http://www.icgi.org/2009/04/circumcision-causes-increase-in-infant-uti/
http://www.jurology.com/article/S0022-5347%2805%2961083-X/abstract (uti’s in women)
http://www.jurology.com/article/S0022-5347%2812%2905623-6/abstract(supportscirc)
http://www.ncbi.nlm.nih.gov/m/pubmed/1544271/?i=22&from=%2F2664681%2Frelated
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2878423/
http://www.ncbi.nlm.nih.gov/pubmed/19231547(pro-circbutstatesmorestudiesneeded)
http://www.ncbi.nlm.nih.gov/pubmed/?term=Kwak+circumcision
http://www.nocirc.org/statements/breastfeeding.php(breastfeedinghelpspreventuti’s)
http://www.pnas.org/content/101/5/1333.full

2 thoughts on “Chapter 12

  1. It seems yhou grant too much importance to Wiswell. You do not emphasize the fact that girls are far more prone to UTIs without being cut.

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